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Compliance Program Overview The goal of VHP’s compliance program is to ensure that all VHP members receive appropriate and quality health care services through the provider network in compliance with all applicable state and federal rules and regulations as well as VHP contractual requirements. Program scope includes but is not limited to: • Provide oversight and ongoing monitoring of delegated responsibilities of VHP’s provider network. • Require the implementation of Corrective Action Plans (CAPs) by providers to address deficiencies concerning the provision of health care services or VHP performance standards. • Establish policies and procedures to identify, investigate, and resolve potential or actual fraud, waste, and abuse (FWA) activities. • Establish education/training opportunities and provide other available resources to assist providers to be compliant with the Health Insurance Portability and Accountability Act (HIPAA) requirements and member rights concerning privacy and confidentiality. • Establish education/training opportunities and provide other available resources to assist providers in achieving and maintaining compliance with state and federal requirements. • Establish education/training opportunities to assist providers with compliance concerns and issues regarding fraud, waste, and abuse.
Audit and Oversight Activities VHP does not delegate its compliance program responsibilities to providers. However, providers are required to comply with all state and federal compliance program requirements. VHP staff works with the provider’s staff to administer compliance activities and implement CAPs to rectify deficiencies. Providers and their staff are encouraged to work with VHP to ensure compliance with all VHP performance standards. To ensure that all VHP members receive appropriate health care services, VHP’s staff perform an annual audit of contractual responsibilities and services delegated by VHP to a provider or provider entity. VHP’s audit program for delegated providers includes, but is not limited to the following activities: • Annual on-site visits and/or desktop audits of providers to ensure compliance with applicable state and federal requirements. • Annual evaluations are comprehensive assessments of the delegate’s performance, including both compliance with applicable standards and the extent to which the delegate’s activities promote VHP’s overall goals and objectives for the delegated function. • Identification and evaluation of deficiencies, and determinations regarding corrective actions, including procedures for ensuring those actions are implemented. • Ad-hoc on-site visits to review provider activities to ensure compliance with program requirements.
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2021 / Provider Manual
CH 21: Regulatory & Compliance Requirements
